Results:

The authors summarize the evidence supporting various practices, including recent large observational trials, and contribute their own recommendations on selected topics. Recommendations from existing consensus guidelines are often compared, and special surgical populations at greater risk of adverse postoperative outcomes are emphasized. The authors cite advantages of individualizing preoperative testing. For example, with the exception of specific conditions including known moderate-severe valvular heart disease with unstable symptoms, suspected hypertrophic cardiomyopathy with risk of dynamic outflow tract obstruction, or planned solid organ transplant, routine use of echocardiography for evaluation of left ventricular function is not recommended.

A proposed algorithm for preoperative assessment is depicted, based on emergent versus nonemergent nature of planned surgery, presence of severe unstable conditions (arrhythmias, severe valvular heart disease, acute heart failure, or acute coronary syndrome [ACS]), previous coronary stenting, and computed risk of perioperative major adverse cardiac events (MACE) according to one of several available online risk calculators. A patient with ≥1% risk of postoperative MACE, based on output from a risk calculator, may proceed to surgery if on optimum medical management and if able to perform ≥4 METs. Patients at ≥1% MACE risk and inability to perform ≥4 METs should only undergo further testing if the results might alter decision making or aspects of the planned perioperative care.

Despite meta-analysis-level data showing significant association between coronary computed tomographic angiography (CCTA) findings and risk of postoperative MACE, CCTA is not currently recommended for preoperative risk stratification. Routine preoperative coronary revascularization is not recommended by the current American College of Cardiology/American Heart Association consensus guidelines, or by these authors, despite the known relationship between coronary disease and postoperative MACE.

Consultation with a cardiologist is recommended in patients with coronary stents, or with abnormal noninvasive stress test results. Factors contributing to postoperative risk in patients with coronary stents include: 1) stent-specific factors (time preceding stent placement [<3, <6, 6-12 or >12 months], stent type [drug-eluting versus bare metal], length of the coronary lesion and stent [longer vs. shorter], and indication for the stent [ACS vs. stable coronary artery disease]), 2) disadvantageous patient factors (age ≥60 years, heart failure, glomerular filtration rate <30 ml/min, and Hg <10 g/dl), and 3) surgical considerations (high procedural risk, high bleeding risk, and urgent/emergent status). Issues that should be addressed during consultation include appropriate timing of surgery, continuation of aspirin when feasible, optimization of lipid-lowering therapy, and strategies to minimize hemodynamic instability.

Postoperative troponin surveillance was deemed reasonable for patients with Revised Cardiac Risk Index >1 during the first 48 hours after surgery, if results would alter clinical management.